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2538475797 FlAGe: 62 STATi O;:WASHING'1'ON DEPAR110IENT OF CORRECTIONS AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATI.ON .To be filled out by ceo: OFFEllOI!R Le. CATA: ~ _______ ,--_, hereby authorize the Yle or dl~osu ... of my health lnformatlon The following individual orofisnization fa authorized. to make' the disclosure: ADO~s!~ 'jfi ~~~ i2~:Ji~- ~~f~ ~~ j'~C)~' . ~C·lI.n.Jk...J::$,J. ~ c:t~Q. 2 . . , .' ,thr£:. (Pi; 'di:-.. ~ t ~~; . - T!'t~ type and date(s) of information to be used or disclosad is a.s follows: , 1. The aceompallyln9 MedIcaL Martju~na JuStlflc;rtJon 10rm. . _. 2. Any other information requested by the Medic.al Dlrec;tor, Washington State Department !'f CorrectIons. " related to my prGScrlptJon for med.Jcal mariluana. ' ' ' , . Purpose fcIr dlselQ$~re: To d.etermine the legitimacy of the patient's ctalm of a ~eed to use medical marJjUana I understand that the inform~tion In my health record may Include InfOrn:latlon relating to sexiJaJly'transmftted "infections, Acquired Immunodeflctency Syndrome (P,.ICSl, or Human Immunodeficl,noy'v'lru6 (HIV). It may also include lnformaflon about behavioral or mental health 'I=r:-.rices ami treatment for alcohol and dlllg abuse:, . -- This lnformaUon may be dledo-sed to and used by the -following Indl'lidual or organIzation! NAME: Medlc:ar Director ACORf:SS: Wa5hlngton State Department of CoTTGQtiona Fax 360 586-9060- .' I u nders!end that I have a rl9nt to revoke thl~ ~uthorilatio". at any time. I unde~lend that If I rev~ke this, . :alithorization I must do so in writing ~nd p'~elJtmy written revix:¢.ion'tc! the Health !nfqrmati6n· Management Ceparlmen~ I· understand that th~ revocatioo will not apply_ to Information tHat -Me already been releaSed in response to 1tIis authOrization. Unless otheiWise revoKSd, ij1\s au!l1ori;z:ation will expire 01) the follOWing date, event, or condition; At the. tarmjnBtI~n of the, (if lett blank, authorization will exPire six (6) months from signing). _ patient's supervfslon by the - ," . Wlahl~gton St&~ Department of eorrectionc . I understand that authorizing the disclosure ~~Jt~Ji!Llnto1!natlon Is vo[un~_ • .ig~rue.6.l$~_tp_sJgnJ!liliL.... _____ -"--_ authorization. I need !'lot sign this farm In order to assure natmant.- I understand that I may Inspect or,copy the Inro~tlon to be usee! or disclosed, as provided In CFR 164.~~4 and. RCW 70.02. 'understand t!'1at any dlsclO$ure. of Informellon cames yJltti It the potential for lin unauthorlzaG redlsdosl.l1'S at'Id may not be prot=ctaell:ly federal or S1ate ponlidentlall~ ru,les. If 1 have' questio!'l$ about disclosure of my health Infcrmation, I may eontact the . RHIT/deslgnee of the facility: -'n"""a=-_______ --:--__ -..:.._~_'___ _ _ po~ 13--035 Rav, O!l1~Joa) OO,C SOO:020DOC 840.020 DOC 6(0.020 L5QAL GOO/LOO~ PDU-6655-3 000465
February 17, 2009 STATE OF WASHINGTON . DEPARTMENT OF CORRECTIONS P.O. Sox.41 i 00 • Olympia. \~/ashir1gton 98504- i 100 Spokane, ViA 99037 DearMr._ I rece~ved your request from CBR Medical, Inc., on January 5, 2009, to appeal the denial of your initial Medicinal Use of Marijuana Verification. In the interest ot'public safety and protection of the community at i'arge, I find, your request for Medicinal Use of Marijuana, while under the.supervision of the Department of Corrections, is denied. . I would encourage you to contln~e to program in a positi~e manner, following the direction of your assigned CCO and your conditions of supervision. Sincerely, Karen Daniels, Assistant' Secretary Community Corrections Division K.D:md cc: Jefferson Overholster, Community Corrections Officer Etta Molett, Com~orrections Supervisor. Field File - DOc-. . Physician's Office: .' . Attn:. Meiissa Leggee CBR Medical. . 3115 E. Mission Ave. Spokane, ViA 99202 " Working Together for SAFE Communities" PDU-6655-3 000466
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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(".- " ~"""'":.~ Inr ... ~ STATEOFW
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i ( Documentation of Physician Auth
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OCT/ Oct. B. LUO~, 11: ::J9AM T ~co
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, ( .....,-.\ ') ',. . ~'. ;' '-UVi
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... ""'"'''' f~ STATEOFWA$HINGTON ~
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Distefano, Monica J. (DOC) From: Se
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eRR Medical, Il1c 3115 E. Mission A
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Fax : ' 3115,E. Mission Ave Spokane
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Or-FENDER 1.0. DATA, j' STATE OF WA
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DoCumentation of Medical AuthoriZat
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'.!, To: C!6R MedicaO,. h'IlC 31)5
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STATE OF WASHINGTON DEPA'RTMENTOF C
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.' .or", g u:,Se J f 'D. G4A() ~~ P
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311S'E. Mission Ave Spokane, WA 992
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''' .. r.~ l~} STATEOFWASHINGTON "1
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j I Documentation of MedicarAuthcir
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, • J ' -1. d; z.. 00 g-' /Vo v.
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Chapter 69.51 A RCW: Medical marij1
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Chapter 69.S1A RCW: Medical marijua
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Chapter 69.511). RCW: Medical111ari
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•• I ! 3115 E. Mission Ave Spok
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OFFENDER 1.0. DATA: STATE OF WASHIN
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I I l- I I tV!. tier f!! (VLA I 4.
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~ra.4~ OFFENOcR 1.0. DATA: { ~ STAT
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Prescriber's Name (Print) License#:
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3115 E. Mission Ave Spokane, WA 992
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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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T.)' ~x.. MARIJUANA MEDICINE'· 'EV
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.,.,... ..,..,.~ f~J STATE OF WASHI
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"'.... ~ . OFFENOeR 1.0. OATA: fnrt
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-----------------------_ Brown, Dam
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Nov. 26. 2008 4:37PM CBR Medical In
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No'v, 26, 2008 4:48PM CB R Me d i c
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.~. :.' '. ATTEN1':tON LAW ENFORCEM
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\"'Ior"'.~ OFFENDER 1.0. DATA: I f
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Wheeler, Judine L. (DOC) From: Sent
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OMNI: Chrollos Quick Search , •
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-...... THCF MEDICAL CLINICS 1813 1
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Prescdbar's Name (pnnt) . Prasc~jje
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- ...-------------- _._.-- _ ..----
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I I do ncit want to ruffle feathers
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Let me know if you have questions f
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Interpretation of Medical Marijuana
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From: Sent: To: Duggan, Brenda J. (
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NIELSEN TO COME UPSTAIRS. CCO NIELS
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Date & Tirpe Created: 12/16/2008 11
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PRIMARY CARE PHYSICIAN AND LOOKED O
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Distefano, Monica J; (DOC) From: Se
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3. High Non-Violent 4. Moderate, an
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, ' ~. With Community Corrections S
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I FW: 380200 Community Supervision
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FW: 380200 COInmunity Supervision o
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Distefano, Monica J. (DOC) · From:
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Distefano, Moriica J. (DOC) From: .
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j I Distefano, Monica J. (DOC) From
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E.... KIOSK reporting may be used i
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RE: 380 200 Community Supervision o
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RE: 380200 Community Supervision of
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to be processed now. If this was re
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FW: 380200 Community Supervision of
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FW: 380200 Community Sup_ervision o
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.... #"""" .... 'l~ STATE OF WASHIN
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Distefano. Monica J. (DOC) From: Di
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" \ Prescriber's Name (Print) PreSC
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Nov, 26, 2008 4:39PM CBR Medical In
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I OFFENDER 1.0. DATA: ..# ....""..'
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Documentation of Medical Authorizat
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Distefano. Monica J. (DOC) From: Se
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11/06/2008 13:05 - PAGE ./"""-1. II
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I:--- j ! -_. Distefano, MonicaJ. (
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Dec .. l0. 2008 1:34PM CBR Medical
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~ec,.10, 2008 1:35PM CBR Med ic"a 1
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Stern, Marc F. 'Dir Hlth Svc' (~OC)
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I J i Date License type: Prescriber
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Distefano, Monica J: (DOC) From: Se
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I. 1 Distefano, Monica J. (DOC) Fro
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STATE OF WASHINGTON . DEPARTMENT OF
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leT/li od. 8. 200~) 1: 3BAM O/llJVO
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No,7218 pP, 3 , UUj C81'\SS #: lice
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OCT/OS/200S/WED 01:39 PM Tael FAX N
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OCT/08/2008/WED 01: 39 PM Tael FAX
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---------_........_........ .. A i
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.Distefano, Monica J. (DOC) From: S
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~ec. 23. 2UUB 9:U,PM' (;~K Medj'cal
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Dec.23. 2008 5:07PM ,CBR Medical In
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THCF.MedlcaI ·Clinics· '"9,-J, .
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., FAX No. 509-921-2346 P.' 004 Pr~
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.. " , Prescriber's Name (Print) Da
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STATE OF WASHINGTON DEPARTMENT-OF C
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. I I 04/15/2009 18: 28 4258595378
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04/15/2009 18:28 4258696378 THCF PA
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Fax 36027706511· Apr 20 2009 04;31
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I ' , ..... MARI3DI2009/MON . 09:30
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MAR/30/200S/MON OS :·31 AM FAX No,
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I. STATE OF WASHINGTON DEPARTMENT O
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MAR/18/200S/WED 03:05 PM FAX No, MA
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OFFENDER I.D. DATA: , I . I· .j i
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1 Distefano, Monica J. (DOC) i From
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[,,'B-' 5fi1/#1 '{iYlQ prescriber's
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Distefano, Monica J. (DOC) From: ,
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. I, Offender Name STATE OF WASHING
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PDU-6655-3 000236
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5j(B L C W~SEM5 . . ; cm:~EVANS, TR
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CBR iviedicai~ inc 3115 E, Mission
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·· ! Jan. 23. 2009 11 :49AM CBR M
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clan, 23, 2009 11: SOAM CBR Me~ical
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,_. ! j 1 Distefano, Monica J. (DOC
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63/64/2609 14:08 2654185559 CBR MED
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03/04/2009 14:08 2064186659 CBR MED
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. CBR iViedicai, inc •• 3115 E.
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ST,\T: OF WAS"INGTON DEPARTMENT OF
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.. Fax CBR Medical, Inc 3115 E. Mis
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03/04/2009 14:18 2064186659 CBR MED
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STATEOFWASHINGTON . DEPARTMENT OF C
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t j. 1 l·, r , ! , i ; . 3115 E. M
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Documentation of Medical Authorizat
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---_._.-» " Distefano, Monica J. (
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STATE O~ WASHItIIGTON DEPARTMENT OF
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j .j I that statement, In conclusio
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Prescriber's Name (Print) License #
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OFFENDER I.D. DATA: STATE OFWASHING
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1813 Born Avenue NE, Suite'#210 Bel
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Prescriber's Name (Print) Prescripe
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01/21/2008" 20:06 2534724155 VEHICL
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#fOr~ . .,;f ~ . {rri'~l STATEOFWAS
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3115 E. Mission Ave . Spokane, WA 9
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·STATE OF WASHINGTOI< DEP.~RTI'iIE
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. p(J !/j~1 ·.;IS-.·j / Prescride
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i I Documentation of Medical Author
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;lan.14. 2009 9:52PM CBR Medical In
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Jan, 14, 2009 9:53PM CBR Medical In
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Ja n,. 14,2009 9:54PM CBR Med i ca
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3115 E. Mission Ave Spokcme, WA 992
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OFFENDGR I,D, DATA: STATE OF WASHIN
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.IL , Documentation of Medical Auth
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J STATE OF WASHINGTON DEPARTMENT OF
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3115 E. Mission Ave 'Spokane, WA 99
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OFFENDER 1.0. OA·I.o.: STATE OF WA
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MARIJUANA MEDICINE- EVAlUATtON CENT
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~flor~1I .J''; ~. I l ~ATE OF WASHI
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-.." OFFENDER 1.0. O"TA: jDE~ . i ~
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GBN Medical lnc, No, 2826 p, 1/20 I
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Uec .. LJ. 2UUB ~:2!JPM No. 2826 P.
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March 23, 2009 STATE OF. WASHINGTON
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t. Page 1 ofl ..,,-;...-.... -. ...
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'I ! I i Prescriber's N~rint) , Lic
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· I, Karen Hamilton, am a physiCia
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Distefano, Monica J. (DOC) From: Ha
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Page 1 of3 Distefano, Monica J. (CO
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Page 3 of3 To: Checo, Ana V. (DOC),
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PageZ of3 . 253-372-6463 office 253
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Jan. ::lU. :.1UU9 1 L: U~PM ~cott L
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OFFENDER 1.0. DATA: STATE OFWASHING
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Scott L. Havsy, DO, DAApM -Board Ce
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I Prescriber's Name (Print) License
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Page 423 and 424: STAT!: OF WASHING"ON DEPART1\lIENT
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Page 441 and 442: UCT/l~/ZUUH/WKU Ul:l1 PM Due WE:;)'
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Page 445 and 446: Dec.23. 2008 ,:31PM GSg Medical Inc
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Page 449 and 450: CO (') -K~ . C c..l)' ,_ .,..,. ADD
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Page 465 and 466: I I , Smith, Sherri K. (DOC) From:
Page 467: ~- 6S/2e/26ee 12:ae 2538475797 PAGE
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Page 483 and 484: Distefano. Monica J. (DOC) From: Se
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Page 495: Documentation of Medical Authorizat
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